MEDICARE: MATTHEW HETRICK IDMT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1710I1003X	Independent Duty Medical Technicians

General Provider Information

NPI Number	:	1821614538
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MATTHEW HETRICK IDMT

Provider Business Mailing Address
First Line	:	340 MAGNOLIA CIR # 5612
Second Line	:
City	:	TYNDALL AFB
State	:	FL
Zip	:	32403-5612
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	340 MAGNOLIA CIR # 5612
Second Line	:
City	:	TYNDALL AFB
State	:	FL
Zip	:	32403-5612
Country	:	US
Telephone Number	:	850-283-7357
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/18/2020
Last Update Date	:	04/03/2024

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